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Products

Suggest edit Updated on January 26, 2021

Products contain information, networks, benefits, and cost shares. In Pega Product Composer for Healthcare, products are built from product templates and are the foundation of standard and non-standard plans that health insurance organizations take to market.

You configure cost shares and variations in a product. Although cost shares are configured as ranges in the product template, the product requires configuration of a specific value from within the range set at the product template level.

Before you begin:

View the default benefit coverage levels and determine if you need to perform tasks in create additional benefit coverage levels.

Ensure that you have configured your product template. For additional information, see Product templates.

Entering details for a new product

Configure a new healthcare insurance product by copying an approved product or using a product template that facilitates the efficient building of a product. Product templates outline the network structure, list of benefits, cost share ranges and defaults, and accumulator design that all support product configuration.

Before you begin: Ensure that you have configured your product template. For additional information, see Product templates.Note: Based on your organization's needs, you can extend the metadata. For additional information, see Extending entity metadata in the Extending the Pega Product Composer for Healthcare application section.
  1. In the header of Dev Studio, click Launch portalProduct Development.
  2. In the left navigation panel of your workspace, click NewProduct.
  3. Click an option to configure a product by using a product template or copying from an existing product and then select the name of the product template or product from the Create or Copy list.
  4. Complete the required fields.
  5. Expand Other properties to view tabs for other categories of properties that you might want to complete to fit your business needs.
  6. Click Save to complete your product at a later time or Continue to configure cost shares and accumulators.

Configuring cost shares and accumulators for a new product

Configure custom individual cost shares for your product by selecting the appropriate cost share types with values for your product. You want to specify the most common values so that when you reach the Configure benefits step of the wizard, you change only those values that need to be modified and maximize the inheritance as much as possible.

In this step of the wizard, you must configure at least one cost share.

If your product has multiple networks, define the values for the first network, for example, In-network, in this section. When you get to the Network step of the wizard, you can just define values for Out-of-network.

If you are configuring your product from a product template, you inherit the values that were configured in the product template. If you are copying a product from another product, you receive the values from the existing product. You can also define the accumulators, the order to apply cost shares during claim adjudication, and information to coordinate benefits. You can override the default order of cost shares for a specific benefit.

Before you begin: Ensure that you entered the details for the product.
  1. Optional: Select the N/A check box only if a particular cost share does not apply.
  2. In the Product cost shares section, select an option in the Calculation method fields and the Value fields for the copayment and coinsurance cost shares.
  3. To specify if these cost shares contribute to the deductible or out-of-pocket expense accumulators, perform the following steps for copayment and coinsurance:
    1. In the Contributes to column, click the Configure the contributions of icon to the right of the field.
    2. In the dialog box, select the check boxes that apply.
    3. Click Submit to ensure that the specified cost share values contribute to the accumulators that you selected.
  4. In the Annual maximum, Lifetime maximum, and Carryover fields for the individual and family, select an option in the Value field. In the Carryover field, you also select a time frame.
  5. In the Deductible and out-of-pocket calculation methods list, select an option for your calculation method. The selected method applies to both deductibles and out-of-pocket maximums.
    OptionDescription
    Policy type You select values for deductible and out-of-pocket expenses that are based on the policy-type tiers that are defined by the product template, product, or plan structures. You also specify whether the deductible contributes to the out-of-pocket accumulators.
    Number of family membersYou enter the individual out-of-pocket maximum dollar amount (in US dollars) and the number of family members who are required to meet the individual out-of-pocket maximum. The system automatically calculates the family out-of-pocket maximum amount. You also specify whether the deductible contributes to the out-of-pocket accumulators.
    EmbeddedYou select the individual and family out-of-pocket maximum amounts (in US dollars) and specify whether the deductible amounts contribute to the out-of-pocket accumulators.
    Subscriber salaryYou enter out-of-pocket maximum amounts (in US dollars) that are based on the subscriber's salary. You can define multiple out-of-pocket maximum amounts that are based on a salary range. You can also define the salary ranges as needed for product template, product, or plan structures. You also specify whether the deductible contributes to the out-of-pocket accumulators.
  6. Based on the calculation method that you select, complete the fields in the Deductible and the Out-of-pocket sections that apply. Guidelines include:
    • Optional: Select the N/A check box if a line item does not apply to your product.
    • If you select Subscriber Salary as a calculation method, configure the salary range.
    • When applicable, click the Contributes to icon to the right of the field, select the boxes that apply, and click Submit.
  7. In the Accumulators section:
    1. Select options from the accumulator lists to specify whether sharing applies.
    2. Click the buttons to specify whether the benefits will contribute to the accumulators.
  8. In the Default order of cost shares section, select a cost share from each list to represent the order in which the cost shares are applied to the benefits during claim adjudication.
    An individual benefit can have its own custom order of cost shares that is configured within the benefit at the network level in a product template, product, or plan. If an order of cost shares is not specified for an individual benefit, the default order of cost shares that is defined in this step applies.
  9.  Click Coordination of benefits (COB) to expand the section.
    1. Select the COB savings eligible check box if the member is eligible to use cost savings from the coordination of benefits toward out-of-pocket expenses.
    2. Enter an amount in the Credit savings amount field.
    3. In the Secondary payment type list, select an option to indicate how this payment works.
    4. In the Cost share exclusions section, select the check boxes to specify the cost shares that are not included in the COB calculation.
  10. Click the Authorization section to expand it.
    Authorizations or penalties that you enter in this step are inherited by all the benefits.
    1. Check the Authorization not applicable? check box if authorizations do not apply to services.
    2. If authorizations do apply, clear the check box and complete the fields to describe the authorization types and conditions.
  11. Click Save to complete your product at a later time or Continue to define network cost shares.

Modifying network cost shares for a new product

To meet the specifications for your product, modify the values for the network coverage and guardrails that are defined in the product from either the product template or another product.

For example, you might want to increase the amount of the cost shares to accommodate out-of-network services because the copayment for an out-of-network service might be higher than the cost of the same service within a network.

Each network line displays the source of the cost shares and the cost share values. If the cost shares for the network are inherited from the product template, the abbreviation PT appears in the Inheritance column. If the cost shares are not all inherited and you manually entered some of them, a Click to view the inheritance pattern icon appears in the Inheritance column. If the cost shares have been overridden, this mark is displayed to show that the inheritance has been broken.

Additionally, you can add or modify variations and network details that are specific to the selected network. And you can control accumulation across the networks.

Network guardrails are applied when products are configured by using a product template. If you defined network guardrails at the product template level, they appear in the Guardrail summary section on the Configure networks page. When configuring network cost shares, if the values are outside the defined guardrails, validations are generated.

For example, you apply a rule that requires the copayment for in-network expenses to be less than or equal to the copayment for out-of-network expenses. When you build a plan by using a product, this rule is enforced during the cost share selection process on the Configure networks page.

Before you begin: Ensure that you configured the cost shares and accumulators for the product.
  1. In the Network cost shares step of the product wizard, in the Networks section on the Configure networks page, click a network name link to update coverage at the network level.
  2. To modify covered and required services:
    1. In the Coverage section, click the Set services required link or the Set services NOT required link, and click OK in the confirmation dialog box.
    2. In the Coverage section, click the Set services covered link or the Set services NOT covered link, and click OK in the confirmation dialog box.
    3. Click Submit.
    4. If you are not making any other changes to the networks, click Continue.
  3. To modify the coverage values in the product:
    1. On the Configure network details page, on the Cost shares and accumulators tab, click Edit.
    2. In the Configure or modify coverage dialog box, select the check boxes for the values that you want to modify, and then click OK.
    3. On the Configure network details page, modify the values as needed in the selected sections, click Save, and then click Submit.
    4. Optional: To restore the original values, click Restore. In the Clear the check boxes to restore values dialog box, clear the check boxes that you previously selected, and click OK.
    5. On the Configured network page, click Save and Mark complete when you are finished editing the coverage values for networks.
    6. For each network whose coverage you are modifying, on the Configure networks page, click the network name link and repeat these steps.
    7. Click Continue if you are not making any other changes to the networks.
  4. To add variations:
    1. On the Configured network details page, click the Variations tab and click Edit.
    2. Click Add variation.
    3. Name the variation, provide the effective and end dates, select the check box for the type of variation, and select a condition type.
    4. Complete the corresponding fields that appear, based on your selections, and click OK.
    5. Repeat steps b through d for each variation that you are adding.
    6. Click Save, then click Mark complete when you are finished adding or editing the variations for the specified network. Click Submit.
    7. For each network to which you are adding variations, on the Configure networks page, click the network name link and repeat these steps.
    8. Click Continue if you are not making any other changes.
  5. To edit network details:
    1. On the Configure network details page, click Edit.
    2. Click the Additional network details tab, and then click Edit.
    3. Complete the fields, click Save to save the changes, click Mark complete, and then click Submit.
    4. For each network to which you are adding details, on the Configure networks page, click the network name link and repeat these steps.
  6. If you have finished making changes, on the Configure networks page, click Mark all as complete, and click Continue.

Configuring benefits for a new product

You can modify the coverage, for example, copayment or coinsurance, for a benefit that was previously included as part of a benefit set or as part of a grouper for a specific network. You add the values for the benefit-specific coverage, for example, deductible or out-of-pocket costs, during this step because these values were not inherited. You can also assign cost shares for specific conditions or assign limits to a benefit. In addition, you can add other benefits and groupers to the product.

For example, when you configure benefits for a product, you might limit physical therapy to 60 visits per year or require an authorization for certain conditions.

Additionally, you can set services that are covered and set services that are required.

Before you begin: Ensure that you modified your network cost shares.
  1. To add a benefit or grouper, follow these steps:
    1. On the Configure groupers and benefits page, click Add benefit/grouper.
    2. Complete the fields in the Add Benefit/Grouper to benefit tree window to add the grouper or benefit and click Submit.Result: The Grouper/Benefit section shows the benefits, groupers, and their cost share values per network.
  2. To modify the coverage of a single benefit, a grouper that contains multiple benefits, or one benefit within a grouper, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon to the right of the benefit or grouper name.
    2. In the Configure details for product window, click the network for which you are modifying the benefit coverage.
    3. In the expanded Configure details for product window, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, in the To edit, select one or more check boxes for corresponding fields section, select the Covered and required check box and click OK.
    5. Based on the specified benefit or grouper, click Covered or Not covered.
      The shaded button shows the current setting.
    6. Click Mark complete, and then click Submit.
  3. To modify the requirement for services of a single benefit, a grouper that contains multiple benefits, or one benefit within a grouper, follow these steps: For example: Some services are required as part of the plan.
    1. On the Configure groupers and benefits page, click the Configure item icon to the right of the benefit or grouper name.
    2. In the Configure details for product window, click the network for which you are modifying the benefit requirement.
    3. In the expanded Configure details for product window, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, in the To edit, select one or more check boxes for corresponding fields section, select the Covered and required check box and click OK.
    5. Based on the specified benefit or grouper, click Required or Not required.
      The shaded button shows the current setting.
    6. Click Mark complete and then click Submit.
  4. To configure the coverage of a new or an existing benefit or grouper, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon at the right of the benefit or grouper name in the list.
    2. In the Configure details for product window, on the Coverage tab, click the network name.
    3. In the Configure details for product expanded window, to update coverage information, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, to update the network coverage values, select the check boxes in the Select the check box to edit the corresponding fields section or the Select the check box to configure the corresponding coverage section that you want to modify and click OK.For example: You might want to increase the values of copayment or coinsurance or change the accumulators. Additionally, you can modify coordination of benefits and authorizations. You also might want to change the values of your deductible or out-of-pocket expenses for the benefit.
    5. In the corresponding sections in the Configure details for product window, modify the values, and then click Save or Save across networks. If you select Save across networks, select the network name check boxes that appear in the dialog box, and click Submit.
    6. To remove one or all changes that you made in steps c through e and restore the original values, click Restore, clear the check boxes in the dialog box, and click OK.
    7. Repeat step 4 to configure or modify each benefit or grouper.
  5. To configure the values and network contributions of annual maximum and lifetime maximum, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon at the right of the benefit or grouper name in the list.
    2. In the Configure details for product window, on the Coverage tab, click the network name.
    3. In the Configure details for product expanded window, to update coverage information, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, select the Accumulators check box. Then based on your business needs, select either the Annual maximum or Lifetime maximum check box, or both, and click OK.
    5. In the Configure details for product window, in the Annual maximum and Lifetime maximum fields, select the values.
    6. In each field, click the Cross network for icon, select one or more network name check boxes in the dialog box, and click Submit.
    7. Repeat step 5 as needed for each benefit.
  6. To specify that a benefit limit in a product applies to multiple networks, follow these steps:
    1. Click the Configure item icon next to the benefit.
    2. On the Configure benefit details page, select a network.
    3. Click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, select the Accumulators and Limit check boxes and click OK.
    5. In the Accumulators section, clear the Limit not applicable check box.
    6. Enter the limit information in the fields.
    7. Click the Configure the cross-network for limit icon, select the networks that apply, and click Submit.
    8. Click Save.
  7. To create or modify variations of benefits or groupers, follow these steps:
    Note: Use variations sparingly and only when you need to configure an item that is not standard. It is better to configure them at the benefit level whenever possible for better transparency and mass updates.
    1. On the Configure groupers and benefits page, click the Configure item icon next to the benefit or grouper.
    2. In the Configure details for product window, click the Variations tab.
    3. Click the network link and then click Edit.
    4. Add or edit variations, click Save, and then click Submit.
    5. Repeat these steps for each benefit or grouper variation that you are creating or modifying.
  8. To configure additional details for a benefit or grouper, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon next to the added benefit or grouper.
    2. In the Configure details for product window, click Additional details.
    3. Click the network link.
    4. In the expanded Configure details for product window, click Edit.
      To meet your business needs, you can configure fields for compliance support, documentation support, and claims instructions.
    5. Click Save and then click Submit.
    6. Repeat these steps for each new benefit or grouper detail that you are creating or modifying.
  9. To review the mapping for a benefit, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon next to the added benefit or grouper.
    2. In the Configure details for product window, click the Mapping tab.
    3. Review the information that you previously entered. Click Mark Complete and then click Submit.
      If you need to make changes based on your review of the Mapping tab, you must modify the specific benefit. For additional information, see Configuring a benefit in Pega Product Composer for Healthcare.
  10. When you are finished configuring benefits and groupers, click Mark all as complete and then click Continue.

Optional: Changing the default benefit

During product creation, the product inherits the default benefit from the product template or a copied product. The default benefit best represents the cost share for the benefit category. The cost share, such as copay or coinsurance, on the benefit category displays in a Summary of Benefits and Coverage (SBC) document or in a sales application when using the Plan API.

In this wizard step, you can also change and add benefit categories. However, if you add a benefit category, there is no default benefit.

Before you begin: Ensure that you configure the benefits.
  1. In the Configure benefit categories step of the wizard, in the Benefit category column, click a tab to expand it.
  2. For the benefit that you are setting as default, click the Gear icon and click Set as default display benefit.Result: The default benefit displays Yes. Other benefits within the benefit category display No.
  3. Click Finish.

Changing or adding a benefit category

When you create a product, you can change the benefit category assignments for the product. For example, you might change the benefit category for the Office visit benefit from Inpatient services as defined during benefit creation to Outpatient services. You can also add a benefit category. However, if you add a benefit category, there is no default benefit.

You can also change the default benefit in this wizard step.
  1. In the Configure benefit categories step of the wizard, in the Benefit category column, click a tab to expand it.
  2. Click the Gear icon to the right of the benefit that you are modifying.
  3. Click Change benefit categories.
  4. In the Change benefit categories dialog box, click Add benefit category and then enter and click a category from the list.
  5. Click Submit.
  6. When you have completed your changes, click Finish.

Selecting SBC metadata

In this step, you select the template that you want to use as the base for the SBC document in your product. Select the required networks from the product that you want to display in the SBC document. You must select at least 1 network; the maximum number of network selection is 3. The first network is considered In-network. You can provide names for the networks and order them as you want them displayed in the SBC document.

Before you begin: Ensure that you have created an SBC template. For more information, see Creating an SBC template.
  1. In the Select SBC metadata step, in the SBC template field, enter and click the specified template.
  2. In the Select network order section, select the appropriate networks.
  3. In the Network name field, enter a descriptive name that corresponds to the network to the left.
  4. If you do not want to generate the SBC document in PDF format, select the Skip SBC PDF Generation check box.
    This means that no SBC document in PDF format will be attached to the product.
  5. Click Continue to display the document.

Editing the SBC document

In the last step of the product wizard, the SBC document that is part of the product displays. You can edit the document and preview it.

  1. To preview the document, click Preview document.
  2. To edit the document by overriding values that were in the SBC template, follow the steps to edit a specific tab in the SBC template section.
  3. When you have finished editing the template, return to the product to complete the step.
  4. To restore all changed values to the values in the SBC document, click Restore.
  5. Click Finish.

Extension rules for SBC in products

You can extend rules for SBC data within the product.

Rule nameDescription
SelectSBCMetadataPreEXTUse this data transform in the PegaPCS-HC-USA-Work-Commercial-Medical-Product class to set additional metadata on the product.
SelectSBCMetadataPostEXTUse this data transform in the PegaPCS-HC-USA-Work-Commercial-Medical-Product class to perform additional validations on SBC metadata in the product.
SelectSBCMetadataPostEXTUse this activity in the PegaPCS-HC-USA-Work-Commercial-Medical-Product class to perform additional validations and actions on the template post-SBC metadata selection in the product.
EditSBCDocumentPreEXTUse this data transform of the PegaPCS-HC-USA-Work-Commercial-Medical-Product class to update data that displays in the SBC document in the product.
EditSBCDocumentPostEXTUse this activity of the PegaPCS-HC-USA-Work-Commercial-Medical-Product class to perform additional validations or any more actions on the data.
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